Quality Management

Continuity & Coordination of Care

Continuity and coordination of care is important to PreferredOne. If your clinic is terminating your contract with PreferredOne please notify your PreferredOne provider representative immediately. According to the Minnesota Department of Health statute 62Q.56 subdivision 1: the health plan must inform the affected enrollees about termination at least 30 days before the termination is effective, if the health plan company has received at least 120 days’ prior notice. If you need further information please contact your network representative at PreferredOne regarding this statute.

Programs from PreferredOne at No Cost to Your Patients

Care Management

What is Care Management?

Care management is a collaborative process between the Care Manager (RNs and Licensed Social Workers), the PreferredOne member, their caregivers, and the care team. The goal of case management is to help high risk members navigate the complex medical system and reduce their risk of unplanned hospital and emergency room visits and poor outcomes by closing/preventing gaps in care. This service is intended to support the work of the care team.

Core Services

Assess individual member needs and develop a care plan with the member and providers to improve the member’s quality of life
Identify resources that may be helpful for the member and provider
Provide both verbal and written education regarding a disease condition
Promote compliance with provider’s treatment plan
Serve as a liaison between the health plan, member and providers

PreferredOne offers condition focused support to help members who have the chronic and episodic conditions listed below. Your patients will still have the same level of benefits, access to ancillary services and access to your referral network. They will also continue to see their practitioner(s) and receive the same services currently provided.

Diabetes
Coronary Heart Disease
Congestive Heart Failure
Chronic Obstructive Pulmonary Disease
Asthma (adult and juvenile)
Multiple Sclerosis
Rheumatoid Arthritis
Ulcerative Colitis
Crohn’s Disease
Rare conditions (Sickle Cell, Cystic Fibrosis, Lupus, Parkinsons, Myasthenia Gravis, Hemophilia, Scleroderma, Dermatomyositis, Myositis, Polymyositis, CIDP, ALS, and Gaucher Disease)
Healthy Mom and Baby

The goals of Care Management are:

Promote self-management of conditions
Address barriers and social determinants of health
Improve adherence to treatment plans
Improve adherence to medication regimes
Reduce or delay disease progression and complications
Reduce risk of avoidable hospitalizations and emergency room visits
Help members save money by understanding and optimizing benefits
Improve quality of life
Maintain high levels of member and provider satisfaction

Care Management Referral

Eligibility and Access

All members of the health plan experiencing complex health needs are eligible for case management. There is no cost for this service and it is confidential. Participation is voluntary.

Health care providers can refer PreferredOne members or members can self-refer by contacting PreferredOne and requesting to speak with a Case Manager. The telephone number to make a referral is 763-847-3456 or email at IHSenrollment@preferredone.com. Include member name, member ID and date of birth.

Benefits to You and Your Practice

PreferredOne programs are designed to increase adherence to the practitioner’s recommended treatment plans. With the help of a PreferredOne nurse or social worker, patients are educated telephonically about their chronic conditions and taught how to track important signs and symptoms specific to their condition. There are several benefits when your patients participate in these PreferredOne programs;

Program participants learn how to better follow and adhere to treatment plan
Program participants learn how to prepare for and maximize their office visits
Program participants receive ongoing support and motivation to make the necessary lifestyle changes practitioners have recommended to them
Case management can assist members who are 17 and need to transition from a pediatric provider to an adult primary care provider

Benefits to Patients

Access to a PreferredOne Registered Nurse or Social Worker
Information about managing their health condition
Education and tools to track their health condition
Access to Healthwise®, an online health library at www.preferredone.com

Program Participants learn to:

Track important signs and symptoms to detect changes in their health status early enough to avoid complications and possible hospitalizations
Make better food choices
Start an exercise program
Regularly take their medications
Avoid situations that might make their condition worse

Questions?

Contact PreferredOne toll free at 1-800-940-5049 Ext. 3456 Monday-Friday 7:00am to 7:00pm CST.

Follow-up Appointments Following Mental Health Hospitalization

Hospitalizations for mental illness are monitored by PreferredOne with the intent on assisting members in their transition home or to another facility. The goal of PreferredOne’s Mental Health Admission Transition Management (ATM) Program is to reduce risk of adverse behavioral health and medical outcomes including readmissions and ER visits after discharge from an inpatient setting by the increasing the number of members who follow up with a mental health provider within seven days of discharge.

Pediatric Care Management / Care Coordination

Minnesota law now requires hospitals to provide care coordination for children with high-cost medical or chronic conditions who need post hospital extended care services or outpatient services or is at risk of recurrent hospitalization or emergency room services by notifying the PCP and Health Plan of the anticipated discharge date, a description of the child’s needs, and a copy of the discharge plan including any necessary medical information release forms. This information can be emailed to IHSenrollment@preferredone.com.

Mental Health Care Management / Care Coordination

In coordination with hospital discharge planners, our Care Management staff can assist members and their care team navigate scheduling an appointment with a behavioral health specialist prior to hospital discharge within the optimal seven-day time frame. The seven-day time frame is strongly encouraged as there is substantial evidence supporting reduced readmissions. We would ask that care teams consider this goal as they work on discharge plans with PreferredOne members and work to schedule the initial follow-up appointment prior to the member being released from the hospital. If our care management team can be of assistance to find an available mental health practitioner appointment in the member’s network please connect with us and we would be happy to help. Please call our Enrollment Specialists at 763-847-3456 and they will assist you. We appreciate you working with our members to achieve this goal and assist them in their healthcare needs.

Is there a doctor in your practice who is not accepting new patients?

PreferredOne is requesting all physicians to submit information regarding acceptance of new patients. If you are a clinic site who has a physician that is not accepting new patients you can go to www.preferredone.com, select For Providers, login, select Your Clinic Providers and edit the Accepting New Patients information for your provider. Our provider directories will be updated with this information.

If you are unable to access the provider secured website please send an alert to PreferredOne by electronic mail to quality@preferredone.com. We would ask that you please include your clinic(s) site name and address, the practitioner(s) name and NPI number who are no longer accepting new patients and the contact information for the individual sending us the notification in case we have questions.

Quality Complaint Reporting for Primary Care Clinics

MN Rules 4685.1110 and 4685.1900 require health plans to collect and analyze quality of care (QOC) complaints, including those that originate at the clinic level.

A QOC complaint is any matter relating to the care rendered to the member by the physician or physician’s staff in a clinic setting. Examples of QOC include, but are not limited, to the following:

Clinical practitioner/provider – knowledge or skill, behavior, attitude, diagnosis and treatment, violation of member’s rights, etc.
Non-clinical staff/facility – competence, communication, behavior, environment (cleanliness, lacking areas for confidential communications, unsafe), violation of member’s rights, etc.

QOC complaints directed to the clinic are to be investigated and resolved by the clinic, whenever possible. PreferredOne's requires clinics to submit quarterly reports to our Quality Management Department as specified in the provider administrative manual. We have attached the form for your reference. If you'd like to have the file electronically please e-mail quality@preferredone.com. If you have any questions or concerns please contact Arpita Dumra at 800-940-5049, ext. 3564 or e-mail arpita.dumra@preferredone.com.

Clinic Complaint Reporting Form.pdf

Reminding Patients of Yearly Preventive Screenings

As the end of 2021 rapidly approaches, we want to encourage all our practitioners to remind and encourage their patients to make an appointment for their annual preventive screenings. In the wake of the COVID-19 pandemic, annual preventive screenings, especially for older adults and those with chronic or pre-existing conditions, decreased. Now with robust vaccination programs and effective safety protocols in place patients can feel safe to visit their primary care practitioner and have their annual preventive screenings performed.

Medical Management

Affirmative Statement about Incentives

PreferredOne does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision-makers do not encourage decisions that result in under-utilization. Utilization management decision making is based only on appropriateness of care and service and existence of coverage.

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Medical Policy

Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration. The most current version of Medical Policy documents are accessible under the Medical Policy section on the PreferredOne website (PreferredOne.com). (Click on Coverage & Benefits then choose Medical Policy).

If you wish to have paper copies of these documents, or you have questions, please contact the Medical Policy Department telephonically at (763) 847-3386 or online at Heather.Thompson@PreferredOne.com.

Prior Authorization List

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies - under Prosthesis, lower limb, microprocessor controlled ankle/foot, or knee, added Ottobock 4R57 Rotation Adapter and HCPCS K1022; Obstructive Sleep Apnea Surgery, Adult – added note, “For adults (age 18 and older) when billed with obstructive sleep apnea diagnosis codes: G47.30, G47.33 & G47.39”; Other Procedures/Treatments: Fetal Surgery In utero - deleted CPT 59074 as this specific procedure no longer requires prior authorization.
Effective 10/1/2021, prior authorization for excision dermoid cyst – nose (CPTs 30124, 30125) is no longer required.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

REVISIONS

Enema system, manual pump-operated: HCPCS A4453 for rectal irrigation catheters added to this entry – the previously designated quantity limit remains in place.
Oral appliances/mouth guard /splint: HCPCS D9947 and K1027 added to this entry (note these are specific to obstructive sleep apnea)
Orthotic Devices, Upper Limb and additions: revised to reflect the entire range of HCPCS, ie, L3650-L3999
Percussive, ventilation systems intrapulmonary: HCPCS E0481 - Eligible changed from Y to N as this is not routinely covered
Pressure Reducing Surfaces: HCPCS E0190 “Positioning cushion/pillow/wedge”, has been moved to a separate entry and the following coverage language has been re-added,

“Non-covered. Not primarily medical in nature. Includes, but not limited to, Zzoma. Exception when used for infants with severe gastroesophageal reflux”
Refractive lenses: Changed from a D to a P, since this is a prosthetic (not a DME item)

DELETIONS: NONE

Medical Clinical Policies

NEW

Chiropractic Services (MC/N009)
Genetic Testing, Preimplantation Diagnosis (MC/L026)

Revised (substantive clinical revisions)

Breast Reduction and Gynecomastia Surgery (MC/G002)
- Addition of indication to allow for a total removal of 1 kg, when the proposed amount of tissue removal does not meet Schnur guidelines
- In reference to potential gynecomastia-inducing medications, added, “ including medical marijuana…”
- In reference to illicit substances known to cause gynecomastia, added, “recreational marijuana use…”
- Attachment A
  – The previous Schnur chart has been replaced with a modified Schnur chart which also includes the amount of tissue that would fall into the lower 5th Percentile
Intervertebral Disc Prosthesis, Cervical and Lumbar (MC/F022) - addition of requirement to correlate issue to targeted surgical site
Varicose Vein Treatments (MC/J001) – Added Exclusion for Sclerotherapy or other treatment for varicose veins less than 3.5mm in size, (eg, spider veins, telangiectasias, reticular veins treatment or injection (CPT 36468) (note this was already noted as excluded on the Cosmetic Treatments clinical policy

Medical Investigative List

Additions

Genetic Testing, Preimplantation - Aneuploidy
Neurostimulation/electrical stimulation, trigeminal nerve – for attention-deficit/hyperactivity disorder (ADHD) in pediatrics; non-invasive/external
Neurostimulation/electrical stimulation, vagus nerve – for prevention and treatment of headache; non-invasive/external
Pharmacogenetic/pharmacogenomic - VKORC1 genotyping to determine drug metabolizer status for all drugs
Ultrasound-guided Percutaneous Ablation of Soft Tissues for Musculoskeletal Conditions

Revisions

Balloon continence device, adjustable compression devices for treatment of urinary incontinence - Revised to state is now allowed or use in men status post prostate surgery, eg, radical prostatectomy, TURP
Cryoablation/cryoneurolysis/cryosurgery - Peripheral nerve damage in lower extremity - revised entry to reflect that this includes iovera° system for knee osteoarthritis

Deletions: NONE

Please visit www.preferredone.com for the most current version.

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PHARMACY

For dermatologists who are prescribing medications that are used to treat psoriatic arthritis (PsA), there must be a proper workup and definitive diagnosis of PsA made for any coverage determination.

Diagnosis of PsA must be made in accordance with community standards and professional guidelines. The diagnosis of PsA should include the following:

Exclusion of other forms of arthritis, including rheumatoid arthritis, osteoarthritis, gout, etc.
Thorough medical history.
Physical examination, including a joint examination
Arthrocentesis and synovial fluid analysis, if clinically indicated
Imaging
Laboratory testing to support evidence of systemic inflammation and to exclude other conditions. These include, but are not limited to, the following:
- CBC with differential and platelet counts
- Blood urea nitrogen (BUN), creatinine, uric acid, and a urinalysis
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
- Rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibody, and antinuclear antibody (ANA)
- HLA-B27 testing

Failure to provide proper documentation supporting a definitive diagnosis of PsA will result in a denial for any service requested to treat PsA in accordance with our coverage determinations guideline policy MP/C009 based on medical standards and accepted practice parameters of the medical community.

Reference

Gladman DD, & Ritchlin C. Clinical Manifestations and diagnosis of psoriatic arthritis. (Topic 7784, Version 22.0; last updated: 05/01/2020) In: Romain, PL, ed. UpToDate. Waltham. Mass.: UpToDate; 2021. www.uptodate.com Accessed 9/30/2021